Journal of Emergencies, Trauma, and Shock
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Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 54-55
Indirect carotico-cavernous fistula following trivial trauma causing secondary glaucoma

1 Department of Ophthalmology, SCB Medical College, Cuttack, Odisha, India
2 Medical Director, Kar Vision Eye Hospital, Bhubaneswar, Odisha, India

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Date of Submission24-May-2020
Date of Acceptance11-Jul-2020
Date of Web Publication23-Mar-2021

How to cite this article:
Panda BB, Nanda AK. Indirect carotico-cavernous fistula following trivial trauma causing secondary glaucoma. J Emerg Trauma Shock 2021;14:54-5

How to cite this URL:
Panda BB, Nanda AK. Indirect carotico-cavernous fistula following trivial trauma causing secondary glaucoma. J Emerg Trauma Shock [serial online] 2021 [cited 2022 Oct 3];14:54-5. Available from:

Dear Editor,

Secondary glaucoma due to raised episcleral venous pressure is rare and often poses a challenging situation for ophthalmologists. It can be idiopathic or can be seen in conditions such as thyroid-related orbitopathy, Sturge-Weber syndrome, and rarely carotico-cavernous fistula (CCF).[1]

The authors report about a 29-year healthy young male who presented with sudden onset of painless vision loss, drooping of the eyelid, and inability to move the eyeball in his right eye for 3 days. He had a history of trivial injury to his right eye with a wooden stick that he sustained while working in his workplace about 20 days back. On examination, his right eye revealed best-corrected visual acuity (BCVA) of 20/125, intraocular pressure (IOP) of 34 mmHg, relative afferent pupillary defect, complete ptosis, a healed scar below the right eyebrow associated with minimal proptosis, and absence of palpable bruit [Figure 1]a. The anterior segment showed scattered subconjunctival hemorrhages throughout the bulbar conjunctiva with minimal chemosis. There were congested deep vessels and total ophthalmoplegia [Figure 1]b. Dilated fundoscopy showed early optic disc pallid edema with tortuous and congested vessels in the right eye [Figure 2]. Magnetic resonance imaging with angiography demonstrated right-sided CCF with bilateral early filling of contrast in the cavernous sinus and dilated superior ophthalmic vein (right > left) [Figure 1]e. These clinical and diagnostic findings confirmed it as a case of CCF with secondary glaucoma. He was treated with anti-glaucoma medications and referred for urgent endovascular intervention. However, unfortunately, the patient deferred our advice. He returned after 6 months with complete resolution of ptosis and ocular motility but with secondary optic atrophy with BCVA 20/400 [Figure 1]c and [Figure 1]d. The IOP at follow-up visit was however uncontrolled with topical antiglaucoma medications, and a trabeculectomy was advised. Although trivial trauma can initiate CCF in a predisposed individual with systemic hypertension or collagen vascular disease, it is unusual to present with a unilateral frozen globe in an otherwise healthy young male.[2] We believe the pathophysiology in our case may be due to a preexisting arteriovenous malformation which might have ruptured due to the trivial injury. Consequently, the increased episcleral venous pressure and vortex venous pressure resulted in raised IOP.[3] The differential diagnoses for this condition are viral conjunctivitis, anterior scleritis, thyroid-related orbitopathy, intraorbital bleed (posttraumatic or neoplastic), internal carotid artery aneurysm, or cavernous sinus syndrome.[4] Although spontaneous resolutions have been reported in 5%–10% of the patients, the risk stratifications of the patients should be performed to intervene early in the high-risk patients. The patient of CCF with associated neurologic deficits, progressive visual loss, altered mental status, intracerebral hemorrhage, and venous thrombosis deserve urgent attention to obliterate the fistulous tract.[5] Meyers et al. reported that endovascular intervention in such patients provides favorable outcome with low procedural morbidity.[5] Our case highlights the fact that early endovascular intervention in patients with optic nerve involvement could have prevented the onset of irreversible changes of glaucomatous optic atrophy.
Figure 1: (a) Clinical photograph showing right eye complete ptosis and a faint healed scar just below eyebrow. (b) Diffuse scattered subconjunctival hemorrhages and frozen globe in right eye. (c) Complete resolution of ptosis in the right eye. (d) Improvement in ocular motility in the right eye. (e) Magnetic resonance angiography showing dilated and engorged superior ophthalmic vein on right side (white arrow) and early contrast filling of cavernous sinus

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Figure 2: Dilated fundus photo of the right eye showing temporal optic disc pallor, tortuous, and congested vessels

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Declaration of patient consent

The authors certify that they have obtained consent from the patient for publication with his images and other clinical information. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Greslechner R, Oberacher-Velten I. Glaukome durch erhöhten episkleralen Venendruck [Glaucoma due to elevated episcleral venous pressure]. Ophthalmologe 2019;116:423-9.  Back to cited text no. 1
Abu SH, Hashim H, George TM, Ngah N, Hussein A. Bilateral indirect carotid cavernous fistula post trivial injury – A case report. J Acute Dis 2013;2:66-9.  Back to cited text no. 2
Chaudhry IA, Elkhamry SM, Al-Rashed W, Bosley TM. Carotid cavernous fistula: Ophthalmological implications. Middle East Afr J Ophthalmol 2009;16:57-63.  Back to cited text no. 3
[PUBMED]  [Full text]  
Mahalingam HV, Mani SE, Patel B, Prabhu K, Alexander M, Fatterpekar GM, et al. Imaging spectrum of cavernous sinus lesions with histopathologic correlation. Radiographics 2019;39:795-819.  Back to cited text no. 4
Meyers PM, Halbach VV, Dowd CF, Lempert TE, Malek AM, Phatouros CC, et al. Dural carotid cavernous fistula: Definitive endovascular management and long-term follow-up. Am J Ophthalmol 2002;134:85-92.  Back to cited text no. 5

Correspondence Address:
Bijnya Birajita Panda
Department of Ophthalmology, SCB Medical College, Cuttack, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JETS.JETS_79_20

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